Case PPOK-Dr Riki Tenggara

7/30/2019 Case PPOK-Dr Riki Tenggara

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Case Presentation

Chronic Obstructive Pulmonary Disease

Advisor : dr. Riki Tenggara, Sp.PD

By : Budi Darmawan (2011-061-078)Aditya Oetomo (2012-061-078)


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Identity

Name : Mr. J

Age : 56 y o

Job : employee Marital status : married

Religion : moeslem

Admission : July 13rd 2013 Date of examination : july 15th 2013


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History taking

Autoanamnesis :

Chief complaint : shortness of breathing

Additional complaint : cough, malaise, night

sweat, black stools.


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History of present illness

2 days before addmission,patient complain about hisblack stool, without mucus and

fresh blood with solidconsistency. Patient have nocomplaint about GIT problem.

Patient complaint shortness ofbreathing for 18 years beforeadmission, and it worsen 1

day before admission.

Patient had been givenofloksacin, INH and etambutollfor 4 month And patient hadbeen given incomplete therapybefore.

Patient feel shortness of breathing

at rest and worse in activity.

Complaint productive coughsince 1 month with unknownsputum because patient cant

cough up the sputum. Patient also complain night sweating,

and malaise


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History taking

History of past illness :

Smoke since 40 years ago and stop 18 years ago (2

packed a day)

Alcohol

TB 18 years ago

Hipertension 5 weeks ago, uncontrolled

DM (-)

Asthma (-)


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Physical examination

General consciousness : Compos mentis

Vital sign :

Blood pressure : 120/70 mmHg

Pulse : 80 x / minute

Respiration rate : 20x/ minute

Temperature : 36.6 degree celcius

Nutritional state :

BMI : 13 (underweight)


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Physical examination

Head and face Normocephali, no deformity, black hair

Eye Anemic conjunctiva -/-, icteric sclera -/-

Ear

No deformity, no secrete

Nose

Septum in the middle, secret -/-, no deformity

Mouth

Dry mucose lip and oral

Neck Trachea in the middle, lypmh glands not palpable, JVP 5+2 cmH20


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Lungs

I : symetric both in static and dynamic

P: stem fremitus dextra=sinistra

P: Hipersonor in both lung

A: vesicular +/+, rales +/+, wheezing-/-


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Heart:

I : ictus cordis visible on 5th ICS linea

midclavicularis sinistra

P : ictus cordis palpable on 5th ICS linea

midclavicularis sinistra

P :

Top margin : ICS III linea midclavicularis sinistra

Right margin : ICS V linea sternalis dextra

Left margin : ICS V linea midclavicularis sinistra


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Abdomen :

I : flat, striae (-), venectation (-), rash (-)

P: tander, liver is palpable 3cm below costae arch,

with regular edge, firm in consistency, no pain in

palpation, kidney and spleen are impalpable

P: timpani, shifting dullness (-)

A: bowel sound (+) 4-5x/minute


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Back

I : symetric both in static and dynamic

P: stem fremitus dextra=sinistra, CVA pain (-)

P: hipersonor in bith right lung

A: vesicular +/+, rales +/+, wheezing -/-


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Genital was not examined

Anus and rectum werent examined

Extremities : edema -/-, CRT < 2 second


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RESUME

From history taking :

2 days before admission : black stools, mucus (-),fresh blood (-), another GIT problems (-)

1 month before admission : productive cough,malaise, night sweating

18 years before admission : shortness of breath,and 1 day before admission get worsen.

History past illness : TB 18 years ago, hypertension 5 weeks ago, smoke 40

years ago and stop 18 years ago and alcohol.


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From physical examination :

Blood pressure : 120/70 mmHg

Heart rate : 80x/minute

Respiration rate : 20x/minute

Temperature : 36,6 degree celcius

BMI : 13 (underweight)


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General examination

Lungs : vesicular +/+, rales +/+, wheezing -/-

Back : vesicular +/+, rales +/+, wheezing -/-

Abdomen : liver palpable 3cm below arch costae


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Assesment

WD/ suspect acute exacerbation of COPD

Differential Diagnosis : Tuberculosis


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DIAGNOSIS

Clinical manifestation theory Findings

Shortness of breath Progressive

Worsen by activity

Persistent

Effort on breathing

+

+

+

+

Chronic cough Intermittent, maybe non

productive cough

+

Chronic productive cough Productive cough -

History Smoke

Poluttion

Chemical substancedaily

+

-

--

We conclude the diagnosis is suspect acute exacerbation of COPD .


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Work up suggestion

Complete blood count

Blood gas analysis

EKG Alfa-1 antitripsin enzym

Chest x-ray

Spirometry


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Laboratory result

Hematologi

Hb 13,3

Ht 37

Leukosit 8700

Trombosit 233000

LED 15

Hitung jenis : Basofil 0

Eosinofil 0

Batang 1Segment 69

Limfosit 28

Monosit 2


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SGOT 23

SGPT 13

Elektrolit : Na 137

K 2,9

Ca 1,03

Cl 101


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Chest x-ray


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X-ray conclusion : now we found tuberculosis

improvement


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Treatment

IVFD RL 500 cc/24 jam

Soft diet 1800 kcal

Nebulisasi combiven 1cc + NS 2cc 3x1 Omeprazole 2x40mg iv

Ofloksasin 2x400mg p.o

INH 1x300mg p.o Etambutol 1x750mg p.o


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Prognosis

Quo ad vitam : dubia

Quo ad functionam : dubia

Quo ad sanationam : dubia


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THEORITICAL BASIS


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CHRONIC OBSTRUCTIVE PULMONARY

DISEASE

defined as a disease state characterized byairflow limitation that is not fully reversible

emphysema, characterized by destruction andenlargement of the lung alveoli

chronic bronchitis, a clinically defined conditionwith chronic cough and phlegm

small airways disease, a condition in which smallbronchioles are narrowed

COPD is present only if chronic airflowobstruction occurs


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RISK FACTOR

Smoke

Ambient air polution

Respiratory infection Occupational exposures

Passive or second hand, smoke expore

Genetic consideration


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Criteria


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Clinical Presentation

cough sputum production

exertional dyspnea

development of airflow obstruction is agradual process

effort to breathe, heaviness, air hunger, or

gasping

worsening dyspnea


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Patophysiology

Airflow obstruction

Hyperinflation

Gas exchange


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PATHOLOGY

Large airway

Small airways

Lung parechyma


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PATHOGENESIS


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Treatment

Stable COPD

Only three interventionssmoking cessation,

oxygen therapy in chronically hypoxemic patients,

and lung volume reduction surgery in selectedpatients with emphysema

symptomatic


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Pharmacotherapy

Smoking cessation

Bronchodilator

Anticolinergik agents

Beta agonist

Inhaled / oral glukokortikoid

Teophyline

Oxygen


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Non pharmacologic therapies

General medical care

Pulmonary rehabilitation

Lung Volume reduction surgery

Lung transplantation


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EXACERBATIONS OF COPD

Exacerbations are a prominent feature of the

natural history of COPD

Exacerbations are episodes of increased

dyspnea and cough and change in the amount

and character of sputum

They may or may not be accompanied by

other signs of illness, including fever, myalgias,

and sore throat


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Treatment Acute Exacerbation

Bronchodilator

Antibiotics

Glucocorticoid

Oxygen

Respiraon failure mechanical venlatory

support


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Thank You

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Case PPOK-Dr Riki Tenggara